ATI Comprehensive Predictor with NGN: Nursing Practice Questions, Exams of Nursing

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A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? - -CORRECT ANS--Ensure the state health department has been notified. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? - -CORRECT ANS-- Evaluate functioning of the suction device. While performing a routine assessment, a nurse notices fraying onto the electrical cord of a client's continuous passive motion (CPM)device. Which of the following actions should the nurse take first? - -CORRECT ANS--Remove the device from the room. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution? - -CORRECT ANS-- Remove the cap and place it sterile side up on a clean surface. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan? - -CORRECT ANS-- Wear loose fitting underwear. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments findings should the nurse report to the provider? - -CORRECT ANS--Sunken fontanels and dry mucous membranes. A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? - -CORRECT ANS--Hypertension A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates understanding of the teaching? - -CORRECT ANS--"I know it will be a couple of weeks before the medication helps me feel better." A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture? - -CORRECT ANS--Align a trochanter wedge between the client's legs. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate? - -CORRECT ANS--Obtain a urine specimen for culture and sensitivity

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? - -CORRECT ANS--INR A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism? - -CORRECT ANS--Shuffling gait A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? - -CORRECT ANS--Having interdisciplinary team meetings for the client on a regular basis. A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? - -CORRECT ANS--Banana slices A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take? - -CORRECT ANS-- Recommend to the provider specific acute care clients for discharge. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? - -CORRECT ANS--A client who was just given a glass of orange juice for low blood glucose level. A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take? - -CORRECT ANS--Hold the client's eyes shut for a few seconds. A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? - -CORRECT ANS--"What are the voices telling you?" A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following as an indication that the medication has been effective?

• -CORRECT ANS--Weight loss A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. - -CORRECT ANS--1. Turn on the suction and set the pressure.

2. Don sterile gloves.
3. Insert the catheter during the client's inspiration.
4. Apply suction while rotating the catheter.

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? - -CORRECT ANS--Hematuria A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating? - - CORRECT ANS--Beneficence A nurse in an emergency department is caring for a child who reports being sexually assaulted by a family member. Which of the following actions should the nurse take? - -CORRECT ANS-- Explain to the child what will happen when the abuse is reported. A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? - - CORRECT ANS--Using an electronic messaging system to remind clients when to take medications. A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? - -CORRECT ANS-- "You don't have to go through with the treatment." A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching? - -CORRECT ANS- -"The more my baby is at the breast sucking, the more milk I will produce." A nurse is preparing to reposition a client who has had a stroke. Which of the following actions should the nurse take? - -CORRECT ANS--Evaluate the client's ability to help with repositioning. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? - -CORRECT ANS--"I should bend at the waist when putting on my shoes." A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? - -CORRECT ANS--Speak directly to the client. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin? - -CORRECT ANS--Acetaminophen A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? - -CORRECT ANS--A client who has a hip fracture and a new onset of tachypnea.

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the clients body should the nurse observe to assess cyanosis? - -CORRECT ANS-- Palms of the hands A charge nurse is teaching staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor for future violence? - -CORRECT ANS--Previous violent behavior A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? - -CORRECT ANS--FHR baseline 170/bpm A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as being complete? - -CORRECT ANS--Digoxin 0.25 mg PO daily A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? - -CORRECT ANS--A client who is ambulatory and receiving oxygen. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) - -CORRECT ANS--- Give the client one simple direction at a time

• Reinforce orientation to time, place, and person
• Establish eye contact when communicating with the client A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? - -CORRECT ANS--How to operate the portable suction machine. A nurse is caring for a client who reports xerostomia following radiation therapy of the mandible. Which of the following is an appropriate action by the nurse? - -CORRECT ANS--Provide humidification of the room air. A public health nurse working in a rural area is developing a program to improve health for local population. Which of the following actions should the nurse plan to take? - -CORRECT ANS-- Provide anticipatory guidance classes to parents through public schools. A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? - -CORRECT ANS--Malaise A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take? - -CORRECT ANS--Instruct the client to avoid coughing during the procedure.

A nurse is auscultating for crackles on a client who has pneumonia. Where should the nurse auscultate? - -CORRECT ANS--The right upper quadrant of the abdomen. A nurse is teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? - -CORRECT ANS--"You can receive the immunization for influenza at anytime during your pregnancy." A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? - -CORRECT ANS-- Avoid using nail polish remover around the client. A nurse is instructing a school-age client who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching? - -CORRECT ANS--"Blow into the meter as hard and quickly as possible." A nurse is caring for a client who is 12 hours postoperative and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? - -CORRECT ANS--Magnesium hydroxide 30 mL PO A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? - -CORRECT ANS--"Perform chest percussion and postural drainage at least twice daily." A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? - -CORRECT ANS--A non-coring needle A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings? - -CORRECT ANS--Hematoma over the insertion site. A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client? - -CORRECT ANS--Deep tendon reflexes of 2+ A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? - -CORRECT ANS--Tell the client, "You seem to be very upset." A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect? - -CORRECT ANS--Spotting A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should

the nurse make? - -CORRECT ANS--"We can provide a copy of your records, but the therapist's notes are not included." A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take? - -CORRECT ANS--The nurse should use a filter needle to withdraw the medication. A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving the treatment? - -CORRECT ANS--Herpes zoster A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? - -CORRECT ANS--Administer a cathartic suppository 30 minutes prior to scheduled defecation times. A nurse is admitting a client who is hesitant to create advanced directive due to concerns about affording legal representation. Which of the following statements should the nurse make? - - CORRECT ANS--"Advanced directives can be a verbal agreement between you and your provider until legal review can be obtained." A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take? - -CORRECT ANS--Elevate the client's arm prior to insertion. A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client? - -CORRECT ANS-- "Do you have thoughts of harming yourself?" A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 minutes ago. Which of the following findings is the nurses priority? - -CORRECT ANS-- Bradypnea A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include? - -CORRECT ANS--Increase dietary calcium A nurse is caring for a client who is receiving penicillin G via IV piggyback. Which of the following actions should the nurse take? - -CORRECT ANS--Instruct the client o notify the provider if diarrhea develops. A nurse is planning care for a school-age child who is 4 hours postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care? - - CORRECT ANS--Administer analgesics on a scheduled basis for the first 24 hours. A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? - -CORRECT ANS--Administering potassium via IV bolus A nurse is providing teaching about using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? - - CORRECT ANS--Position both hands on the grips with his elbows slightly flexed. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? - -CORRECT ANS--"I can visit my nephew who has chickenpox 5 days after the sores have crusted." A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles? - -CORRECT ANS--Implement firm but flexible boundaries in their relationship. A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider? - -CORRECT ANS--Partial separation of the upper part of the incision line. A nurse is caring for a client who has generalized petechiae and ecchymosis. The nurse should expect a prescription for which of the following laboratory tests? - -CORRECT ANS--Platelet count A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet? - -CORRECT ANS--Fish A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase? - -CORRECT ANS--Hip arthroplasty one week ago. A nurse is caring for a school-aged child who is 2 hours postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take? - -CORRECT ANS--Apply continuous pressure 2-5cm (1 in)below the percutaneous skin site. A nurse is planning care for a client who has a prescription for continuous enteral feeding through an NG tube. Which of the following actions should the nurse plan to take? - -CORRECT ANS--Measure gastric residual volume every 4 hours. A charge nurse is concerned about a recent increase facility-acquired catheter infections. Which of the following actions should the nurse take first? - -CORRECT ANS--Identify possible precipitating factors related to the infections.

A charge nurse is delegating care for a group of clients. Which of the following tasks should the nurse assigned to a licensed practical nurse? - -CORRECT ANS--Perform a sterile dressing change for a client who has an abdominal wound. A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take? - -CORRECT ANS--Limit oral feedings to 30 min in length. A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? - -CORRECT ANS--Compare the new prescriptions with the list of medications the client reports. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse? - - CORRECT ANS--Waits for 2 minutes between suctions. A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take? - -CORRECT ANS--Assign the child to a negative air pressure room. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? - - CORRECT ANS--A client who is one day postoperative following a vertebroplasty. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? - - CORRECT ANS--Swelling of the face A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? - -CORRECT ANS--Maternal hypoglycemia A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray? - -CORRECT ANS- -Scrambled eggs and toast with milk. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? - -CORRECT ANS--"I will need to keep my hand elevated above my heart for several days." A nurse is planning care for a toddler who has epiglottis. Which of the following interventions should the nurse include? - -CORRECT ANS--Continuously monitor the child's respiratory status.

the following actions should the nurse take? - -CORRECT ANS--Assist the adolescent in applying for Medicaid. A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take? - -CORRECT ANS--Isolate the client from staff who are pregnant. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing a hemorrhage? - -CORRECT ANS-- Frequent swallowing A nurse is caring for a client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first? - -CORRECT ANS--Determine the client's knowledge about diaphragm use. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? - -CORRECT ANS--Sit with the client to provide sense of security. A hospital nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? - -CORRECT ANS--"I can give you information about respite care if you are interested." A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take? - -CORRECT ANS--Use the palpatory method to determine blood pressure. A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make? - -CORRECT ANS--"Would you like to speak to a spiritual advisor?" A Nurse is Caring for a Client Who Has Diabetes Mellitus. Which of the Following Instructions Should the Nurse Include in the Teaching? - -CORRECT ANS--Limit Intake of Sugary Foods and Beverages. A Nurse is Providing Discharge Teaching to a Client Who Had a Total Hip Replacement. Which of the Following Statements by the Client Indicates Understanding of the Teaching? - -CORRECT ANS--"I Will Use an Elevated Toilet Seat at Home." A Nurse is Caring for a Client Who Has Chronic Obstructive Pulmonary Disease (COPD). Which of the Following Findings Should the Nurse Report to the Provider? - -CORRECT ANS--Increased Respiratory Rate and Use of Accessory Muscles. A Nurse is Teaching a Client About Managing Hypertension. Which of the Following Instructions Should the Nurse Include? - -CORRECT ANS--Monitor Blood Pressure Regularly at Home.

A Nurse is Providing Discharge Teaching to a Client Who Had a Stroke. Which of the Following Statements by the Client Indicates Understanding of the Teaching? - -CORRECT ANS--"I Will Attend Physical Therapy Sessions as Recommended." A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? - -CORRECT ANS--Calf pain Numbness in the arms Intense headache A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

• -CORRECT ANS--Compress the drain reservoir after emptying. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? - -CORRECT ANS--Glucose 272 mg/dL A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? - -CORRECT ANS--Troponin I 8 ng/mL A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? - -CORRECT ANS--hypertension A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? - -CORRECT ANS--Walk for 30 min four times per week. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - -CORRECT ANS--Place a pressure bag around the flush solution. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? - -CORRECT ANS--PaCO2 56 A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? - -CORRECT ANS--Flex the foot every hour when awake. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? - -CORRECT ANS--Place a tracheostomy tray at the bedside. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - -CORRECT ANS--A

Temperature 37.6° C (99.7° F) Heart rate 114/min Respiratory rate 22/min Blood pressure 88/54 mm Hg Oxygen saturation 93% on room air Diagnostic Results Hgb 18 g/dL (12 to 16 g/dL) Hct 54% (37% to 47 %) Total WBC count 11,000/mm3 (5,000 to 10,000/mm3) Troponin T 0.04 ng/mL (less than 0.1 ng/mL) Medical History. History of hypertension. Acute myocardial infarction 1 year ago. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. - -CORRECT ANS--The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? - -CORRECT ANS--Change position every hour A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? - -CORRECT ANS--avocados

• -CORRECT ANS--Vital Signs Blood pressure 155/98 mm Hg Heart rate 98/min

Respiratory rate 14/min Temperature 38.4° C (101.1 ° F) Medication Administration Record Gentamicin 60 mg intermittent IV bolus Q8H Ceftriaxone 1 g intermittent IV bolus BID Morphine 2.5 mg IV bolus Q3H PRN for pain Acetaminophen 650 mg PO Q6H PRN for fever greater than 38 °C (100.4° F) Laboratory Results WBC count 13,700/mm Serum creatinine 2.1 mg/dL Hemoglobin 10 g/dL A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? - -CORRECT ANS--Serum creatinine A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? - -CORRECT ANS--Warfarin A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? - - CORRECT ANS--"Increase fiber intake to avoid constipation." A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? - -CORRECT ANS--INR 2. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? - -CORRECT ANS--"I can speak with the provider about incorporating acupuncture into your treatment plan."

Heart rate 125/min Respiratory rate 28/min Temperature 36 ° C (96.8° F) Blood pressure 145/90 mm Hg Sa0, 90% on oxygen 2 L/min via nasal cannula 2345: Temperature 35.9° C (96.6° F) A Heart rate 135/min Respiratory rate 34/min Blood pressure 96/45 mm Hg Sa0, 92% on 40% face mask Diagnostic Results Hematocrit 26% (Male 42% to 52%) Hemoglobin 8.7 g/dL (Male 14 to 18 g/dL) WBC count 9,000/mm? (5,000 to 10,000/mm3) Platelet count 148,000/mm (150,000 to 400,000/mm3) Lactate (arterial) 5 mg/dL (3 to 7 mg/dL) Provider Prescriptions Transfuse 2 units of packed RBCs. Prepare the client for chest tube insertion. Initiate NPO status.

Select the 3 findings that require follow-up by the nurse. - -CORRECT ANS--Oxygen saturation is correct. The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplemental oxygen. Pain level is correct. The nurse should follow up on the client's pain level. Wound drainage is correct. The nurse should apply a pressure dressing to control bleeding. Complete the following sentence by using the lists of options. - -CORRECT ANS--The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings The nurse should first address the client's blood pressure followed by the client's oxygenation - - CORRECT ANS--Oxygenation and blood pressure are correct. Using the airway, breathing, circulation priority framework, the nurse should first address the client's oxygenation, followed by the client's blood pressure. The client's oxygenation is below the expected reference range and is the priority. The nurse should then address the client's circulation because the client's blood pressure is below the expected reference range. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. - -CORRECT ANS--Transfuse packed RBs is anticipated. The client's increased heart rate and decreased blood pressure indicate decreased circulating blood volume due to trauma. Therefore, the nurse should anticipate transfusing packed RBCs. Place the client in Trendelenburg position is contraindicated. Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their head of bed no more than 30 ° to promote venous return to the heart. Prepare the client for chest tube insertion is anticipated. The client has manifestations of a hemothorax. Therefore, a chest tube is indicated. Cover the client with a cooling blanket is contraindicated. The client's temperature is below the expected reference range, which is a manifestation of hypothermia. Therefore, covering the client with a cooling blanket is contraindicated. Initiate NO status is anticipated. The client might require a surgical procedure. Therefore, the nurse should anticipate initiating NPO status. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? - -CORRECT ANS--Place the client in high- Fowler's position is correct. The nurse should place the client in high-Fowler's position to promote drainage of the hemothorax.